Saturday, November 21, 2009

How to Guarantee Disparities in Health Outcomes: A Primer

Bradford Gray, PhD, a distinguished health services researcher has published a very important study which demonstrates yet another reason why our health care system is designed perfectly to get the disparities in health outcomes that result.(1) Dr. Gray and his colleagues concluded that “minority patients in the New York City area are significantly less likely than whites to be treated at high-volume hospitals for cancer surgeries, cardiovascular procedures, and other services for which high volume and positive outcomes are related”. In other words, racial and ethnic minority patients are much more likely to get essential procedures done at hospitals that do fewer of them per year – a factor well known to contribute to poor health outcomes.

For those of us who provide health services in New York City none of this is a terrible surprise. We all know that those specialty hospitals that advertise on radio and television that they provide the best care in their field – Memorial Sloan Kettering for cancer, Joint Disease and the Hospital for Special Surgery for orthopedics, NYU’s Rusk Rehabilitation Institute and Calvary Hospital for end of life care – all have among the lowest rates of admissions for the uninsured and those on Medicaid.(2)

There are many reasons for this, as we have come to learn. For one, most Medicaid patients are in managed care now and hospitals and managed care companies must negotiate rates in order for the hospital to be considered "in-network" and thus accessible by people who have chosen to enroll in that managed care company. But as we have learned from folks at Sloan-Kettering, no Medicaid managed care company want to contract with them for their Medicaid enrollees. With a reputation as the only specialized cancer center in New York City, a single managed care company that puts Sloan-Kettering in its network will find itself the plan of choice for people with cancer, thus driving up its costs and reducing its profits. The same dynamic will take place for the other specialty hospitals as well. Do patients know, when the sign up for a particular managed care plan that it will likely restrict them from recieving services at the highest volume specialty hospitals if and when they come to need them? I think not. Young people don't sign up for a managed care plan thinking that they might develop cancer - yet when they do - and find themselves unable to go to a specialty hospital for treatment - they unknowingly become a potential victim of health disparities - treatment at a lower volume hospital with a potentially poorer outcome. Sad, when we are talking about the basic human right - the right to live.

There are no villians here. The facts are that we continue to create - through policies in the State, through limitations in funding, through a competitive rather than a cooperative marketplace of health plans, hospitals and doctors - a system that perfectly produces the disparities in outcomes that we achieve.

Bronx Health REACH is a consortium of over 40 community and faith based organizations that has been working in the Bronx for over a decade to reduce – no, eliminate – disparities in health care treatment and health outcomes. We have been working to change the policies which create racial disparities in out-patient care in the voluntary hospital sector in New York City. In facilities that operate “clinics”, the clinics are the places where the poor are treated in a system that provides care that is inferior in many aspects to the “private” care given in other parts of the system. Students, interns and residents - often supervised by a rotating group of attending physicians – are the main health providers that patients see. Troublingly, these doctors rotate monthly through the clinics making continuity of care almost impossible. The clinics have very limited ability to coordinate care with referring community physicians, another cause of discontinuity. Obviously, these doctors are also the least experienced, and these factors together explain, with an unproven yet logical extension of Dr. Gray’s research, another reason why outcomes can be expected to be worse. Everything that contributes to inferior care contributes to the premature death and disability people of color in New York experience.

Like I said before, the system of care in New York is designed to get just the disparate outcomes it achieves. Let’s redesign it.

1. B. H. Gray, M. Schlesinger, S. M. Siegfried et al., Racial and Ethnic Disparities in the Use of High-Volume Hospitals, Inquiry, Fall 2009 46(3):322–38
2. New York State SPARCS Hospital Discharge Database,Table IX


e-Patient Dave said...

I completely get your points. I'm sure it wasn't intentionally designed to create those outcomes but I know what you mean, that the current structures will predictably produce those outcomes.

Where should we start? (I have my own thoughts but I wonder what yours are. Heaven knows many people act as if it's hopeless...)

Eric said...

Eric G. Gayle, MD, F.A.A.F.P
Lets improve the primary care providers' role to help in this. Stop “conveyor belt medicine “/ ( Walmart medicine ( low reimbursement necessitates higher volume of patients!)
As surmised by Dr Calman the findings of Dr Gray's research is not surprising. But what role does the patient’s PCP play in propagating health disparities if they are not better able to provide preventative care to their patients thus reducing the need for tertiary care interventions?
It is why I believe that part of the necessary change to improve health outcomes for the patients of the city of New York must be in the community health centers that provide services to the vast majority of patients. Community Health Centers must be better at caring for the patients that they see on a daily basis. In order to achieve this community health centers will need to change the time allotted to providers to see patients and become -Ideal medical practices for comprehensive medical care. Medical Home?
This should mean fewer patients to be seen and more time to spend with each patient to better understand their health and their health needs. Comprehensive and preventative health of those who need our services more is not easily achieved in an office visit that lasts 10- 15 minutes with the provider. Coordination of the care of the patient also takes time involving follow ups of patient, follow ups of specialists to whom referral are made, following up on those recommendations made etc. Again primary care providers need the time to be able to do a decent job of this to help minimize the need for tertiary care at Hospitals we know do not provide the best of care for reasons already noted in Dr Calman’s blog. There may be concerns that such a move would limit access to care for many. But I also believe that the need for access is also driven by the limited access even for those who see their providers and still leave with many of their health questions unaddressed, and for the doctor the fear of asking the patient “ is there any thing else you are concerned about?” while leaving the exam room.
Community health centers need to work towards improving the quality in health deserved of each patient. But in order to do so they will need to sacrifice their volume in patients seen.
The inherent deterrent of reimbursement makes the CHC role not so much different in priming health disparities.

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